Without a doubt, the health care discussion in Washington is the most pressing public policy debate medicine has seen in the last 15 years. While the outcome is unknown, all legislation is as much process driven as it is policy driven.
And it's driven by real grassroots action. That's where you make the difference.
When your U.S. representative comes home for Congress' August recess, please visit with them and share your hopes, concerns, and fears about what we've seen at the Capitol so far this year. Because the Democrats control both houses of Congress, it is especially important that physicians with Democratic representatives take the time to visit with them.
What's Happened in Congress So Far
We recently shared with you a letter the Texas Medical Association sent to the Texas congressional delegation regarding H.R. 3200, the bill devised by the Democratic leadership in Congress. That letter specified those portions of H.R. 3200 that we think require significant changes. Look for more details below.
Beyond the issues, we need to take a closer look at the legislative process. The House of Representatives has chosen to draw one bill, H.R. 3200, and work it through its three committees with health care jurisdiction: Ways and Means, Education and Labor, and Energy and Commerce. The first two committees have completed their work on the bill. Energy and Commerce has not, largely because of the large number of conservative Democrats, known as "Blue Dogs," on the committee who pushed strongly to reduce the cost of the bill and for other changes. The Blue Dogs and committee leaders reached an agreement earlier this week, and the committee is expected to complete its work today. Under the agreement, the bill won't come up before the full House until September.
The Senate, on the other hand, is working with two bills. One already has won approval from the Health, Education, Labor, and Pensions Committee. The other, the likely basis for an eventual Senate bill, will come from the Senate Finance Committee. Its chair, Sen. Max Baucus (D-Mont.), has been working unsuccessfully for the past several months to craft a bipartisan bill. He and the committee's ranking Republican member, Sen. Charles Grassley of Iowa, continue their discussions, and we assume they will have something on paper shortly. The Senate leadership has indicated that the full Senate also will not vote on any health care reform bill until after the August recess.
Beyond that, the two bills – each as passed by the House and the Senate – will have to be negotiated in a joint conference committee. At this point, we cannot give you an accurate timeline on the outcome in either chamber, what will emerge in terms of legislation, or how and when a conference committee of senators and representatives will work. If a final bill is crafted, both chambers must approve it before they submit the single, final bill to President Obama for his signature. Or veto.
That is precisely why we remain involved as this issue moves through the process. H.R. 3200 is not the final version but a beginning point. As legislation moves through each chamber, our challenge is to address the concerns we have with this bill and to help our patients understand its consequences. The end game is focused on what comes out of the conference committee, but it is critically important for us to refine pieces of the House and Senate bills along the way.
Given the timeline, the August recess gives us the perfect opportunity to meet with the Texas delegation and tell them what's important to physicians and our patients.
Issues of Concern
Earlier this month, TMA asked the Texas congressional delegation to help us achieve some very necessary changes in H.R. 3200. These are:
- A permanent fix of Medicare's sustainable growth rate (SGR) payment formula;
- The lack of liability reforms for the rest of the country or protections for the very effective reforms we have enacted in Texas;
- Protecting patients' access to innovative and high-quality physician-owned facilities;
- Making sure that payments from any public plan are based on negotiated rates rather than hardwired to the Medicare payment system; and
- Making even tougher the health insurance reforms already in the bill, such as the elimination of coverage denials for preexisting conditions.
Here are some talking points on each of these issues to help you in your meetings with your representative and Senators Hutchison and Cornyn.
- Because of the way it is structured, the SGR tracks neither the growing demand for services for elderly patients, nor our cost of providing those services. Working with a fixed pot of money, the SGR has forced the government to project cuts in physicians' Medicare payments each year in order to balance the budget.
- Every year since 2002, Congress has stepped in at the last minute to stop the payment cut – and paid for it by borrowing against funds set aside for future years' payments. Like a revolving door, this borrowing has increased the size of the cuts needed to balance the budget in succeeding years. If no action is taken this year, the government will cut physicians' Medicare payments by 21.5 percent in 2010.
- H.R. 3200 would take some important steps. It would stop the 21.5-percent cut for next year and basically erase the accumulated debt. But the bill would not do away with the fatally flawed SGR, which would bring the problem right back again. TMA is asking Congress to replace the SGR with a rational Medicare physician payment system that automatically keeps up with the cost of running a practice and is backed by a fair, stable funding formula.
- TMA also is asking Congress to amend H.R. 3200 so that it eliminates the arcane law that prevents a patient and physician from contracting privately for services outside the Medicare payment system.
- The SGR formula and other Medicare restrictions are forcing physicians to choose between taking care of our patients or keeping open the doors of our practices for all patients. We will never be able to care for the medical needs of the baby boomers now entering the Medicare system with a continually shrinking network of physicians.
Health Insurance Reform
- From the passage of the Patient Protection Act in the 1997 Texas Legislature, TMA has been a leader in health insurance reform on behalf of our members and our patients. H.R. 3200 gives us a great opportunity to win passage of some of the reforms we pushed for in the state legislature this year.
- H.R. 3200 as written would outlaw coverage denials for preexisting conditions, control premium increases, require health plans to demonstrate they are providing access to an adequate network of physicians, and address medical loss ratios. We support these significant improvements.
- We believe Congress needs to bring additional transparency and accountability to this industry. Physicians and patients need easy, accurate ways to see exactly what benefits are covered, how claims will be paid, and how much our patients will have to pay out of pocket. We need to do away with arbitrary, claims-based physician-ranking systems.
- If all else fails, Congress needs to return to the states the responsibility and authority to regulate all health insurance plans.
- The bottom line is this: Congress needs to hold health insurance companies accountable to the promises they make for the premium dollars they receive.
Medical Liability Reform
- As you know, Texas' 2003 medical liability reforms have significantly enhanced access to care for sick and injured Texans. As the epidemic of lawsuit abuse has waned, Texas has enjoyed a historic influx of highly qualified physicians. Dozens of rural and medically underserved counties now enjoy the services of high-risk specialists, such as emergency physicians and obstetricians. Physicians who once turned away high-risk patients for fear of a lawsuit are now expanding their practices and offering new, lifesaving treatments.
- It is absolutely critical that any action taken at the federal level preserve the effective liability reforms currently in place in states such as Texas and California. We strongly oppose any efforts to overturn strict state health care liability reforms.
- H.R. 3200 would consider numerous changes that could bring liability protections to all Americans, but it omits the one change that has been the single most important factor in Texas' recent success: significant caps on noneconomic damages.
- Significant national medical tort reform could help reduce the soaring costs of health care by eliminating expenses for the tests and treatments that make up "defensive medicine."
- H.R. 3200 would impose stark limitations on physician ownership of hospitals and other health care facilities. It would prohibit physician-owned hospitals from growing, except under very limited circumstances; force physician-owned facilities currently under construction to be abandoned; and uniformly deter the establishment of new physician-owned facilities by prohibiting them from treating Medicare and Medicaid patients.
- H.R. 3200 would place limits on existing physician-owned hospitals, would put them at a competitive disadvantage, and would make it difficult for them to respond to the health care needs of their communities.
- We believe that the innovation and excellent patient care that has come from such leading physician-owned institutions as the Mayo Clinic and Scott & White Clinic are exactly what Congress needs to promote now.
- TMA strongly supports responsible physician investment in technology, facilities, services, and equipment. The focus should be not on who owns the medical facility – a physician, a nonprofit entity, or a for-profit company – but on the quality of the facility and appropriateness of patient care.
Public Insurance Option
- The so-called "public option," which would provide coverage to the uninsured, is one of the most rapidly changing pieces of the health care bills under consideration. Despite these changes, we remain gravely concerned that this "option" will soon become the controlling payer in all health care. The result would be the unworkable government price-setting scheme we now see for Medicare.
- We insist that any public insurance option have these protections for physicians and our patients:
- Individual physicians should have the choice of whether to participate;
- Physicians and patients should have the choice of privately contracting outside of the system; and
- Physician payments must be based on negotiated market rates, not Medicare rates.
We promise to share information with you and continue to ask for your help when it is most needed. In the meantime, please track the issue on our Web site, www.texmed.org. Remember, this is an issue likely to play out over the next several weeks or months. It will not be determined tomorrow or next week. There is a lot of policy to push through an arduous process.
Thank you for all you do for your patients and our profession. Stay in touch. And stay involved.
William H. Fleming III, MD
Texas Medical Association
District Offices for Senators Hutchison and Cornyn:
Austin (512) 469-6034
Dallas (972) 239-1310
Houston (713) 572-3337
San Antonio (210) 224-7485
Harlingen (956) 423-0162
Lubbock (806) 472-7533
Tyler (903) 593-0902
Dallas (214) 361-3500
Houston (713) 653-3456
San Antonio (210) 340-2885
Austin (512) 916-5834
Abilene (325) 676-2839
Harlingen (956) 425-2253